Audits. section 13. Contents

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1 section 13 Audits Contents What are audits? Audit procedures Risk assessment audits Technique audits Training audits Equipment audits Facility audits Bariatric audits References and resources Appendix: Moving and handling audit form. 365

2 13.1 What are audits? A crucial step in the process of managing moving and handling programmes is to monitor and review the effectiveness of programme components. Audits are a specific part of monitoring and review. They are necessary to make sure that the systems are working as intended, and to assess the extent to which appropriate systems are operating systematically throughout the workplace. Audits are a monitoring procedure used to find out to what extent a programme or system is operating as planned and require specific checks such as the observation of programme activities. They often involve checklists that record whether specific items or activities comply with the patterns expected. Audits should provide information that leads to improvements in the operation of moving and handling systems. It is inappropriate to use audits to penalise staff or ward managers or supervisors. Whoever carries out an audit should plan to communicate the audit findings to the unit managers with the intention of improving staff performance and safety, the care and safety of clients, and the work environment overall. It is important to consult a range of staff, particularly those who have worked with audits. Staff should Box 13.1 What gets watched gets done: the value of audits After a spot audit of a particular hospital in our District Health Board (DHB), we found that some wards only had about 10% compliance with requirements for moving and handling tasks. Until then, there had been no audits for a long time. That level of compliance was far below the other hospital in our DHB, which carries out spot audits more regularly. It is really a case of what gets watched gets done. Source: DHB employee also be informed of the findings in a manner that does not spotlight individuals, especially if there are issues of non compliance. The outcomes from audits enable managers to assess how well moving and handling programmes are working. They also gauge the level of compliance by staff with expected practices for moving and handling. Audits should also identify potential areas of concern, and validate and review information or data for completeness and accuracy. Audit information must be documented and communicated back to the manager or supervisor of that area, so safety for clients and staff can be maintained, and to address specific issues or potential issues identified. 366

3 Section 13: audits Types of audit Common types of audit are shown in Table These include routine or scheduled audits, spot or random audits, and audits in response to adverse outcomes. Audit information is collected using one or more procedures such as: Observing staff at work Interviewing staff Checking client profiles or records (e.g. risk assessments) Interviewing clients Walkthrough audits to check equipment. The most common way of collecting information is using a checklist, noting compliance or non compliance through observations and written records. Examples of checklists are shown later in this section. Routine or scheduled audits are planned at regular intervals to obtain estimates of compliance levels with moving and handling practices. The frequency of scheduled audits depends on the availability of resources, and whether audit information is needed to assist in decision making at specific times during the year. Table 13.1 Types of audit Audit type Routine or scheduled audits Spot or random audits Adverse outcomes audits Comprehensive audits as part of major programme evaluations Description Audits scheduled at regular intervals to estimate compliance levels with moving and handling practices Audits carried out at short notice with staff receiving no prior notification of the audits Audits carried out following specific incidents, injuries or near misses to determine any patterns of incidents or injuries Series of audits carried out as part of major evaluations of moving and handling programmes Spot and random audits are unscheduled audits, usually initiated by health and safety managers or moving and handling coordinators, and may be used to target areas with high accident or incident rates. Spot audits are typically performed to ensure compliance in areas where the need for compliance is high. Ideally spot audits should be conducted regularly during the year and, when the need arises, information from spot audits can be used by managers to decide whether immediate action is needed to avert any potential problems. Spot audits may involve observing staff conducting moving and handling tasks, such as risk assessments, transfer techniques, and using equipment such as hoists and slide sheets. Client records such as the HASI and client profiles can be checked against clients mobility levels to determine whether risk assessments are accurate. 367

4 Adverse outcomes audits are carried out following specific injuries or incidents to determine whether there are particular patterns of client transfers related to incidents, staff absenteeism or sick leave. These audits are generally conducted by senior managers. It is important to look for underlying reasons for higher rates of injury and absenteeism, and areas where serious incidents have taken place, even if they were isolated cases. It may also be useful to focus on areas that have recorded falling rates of injury or absenteeism, because there may be lessons to be learnt from these trends. Comprehensive audits may be carried out as part of major evaluations of moving and handling programmes (see Box 13.2) in multiple facilities and workplaces. Often such audits are organised by regional or national authorities to provide overviews of moving and handling programmes in health and residential care facilities. Such audits have been used in Australia and in other countries that have national or federal agencies responsible for health and safety in workplaces. 1 Box 13.2 Example of a national audit in Australia using multiple data sources from different locations An audit report for the health and community services industry provides a summary of the industry s performance following a National Manual Handling Campaign in 2004.The evaluation of industry performance included the following data: Audit data obtained during audits of 643 randomly selected workplaces (171 hospitals and 472 aged care facilities) Information obtained from eight focus groups involving 62 workplace health and safety inspectors and other relevant occupational health and safety staff. Source: Design 4 Health, 2005, p. 4 Who carries out audits? Routine audits are usually conducted by unit managers, supervisors or moving and handling coordinators. Occupational health and safety (OHS) managers or representatives usually organise audits, and have overall responsibility for collating and analysing audit records, reporting audit outcomes and determining overall compliance with organisations moving and handling policies. Unit managers or supervisors can delegate spot audits to nurses, rotating them during the year so that all their nurses get to participate in audits. Nurses in New Zealand are required to carry out audits as part of their annual professional development. It is useful for nurses to audit different wards or units from their own work areas. Community and district nurses should also be included See, for example, Design 4 Health (2005) and Aged Care Association Australia NSW (2008).

5 Section 13: audits Community carers also need to be audited. As there may be resourcing issues with organisations and people providing services to those living in the community, home carers need to have access to people suitably qualified to carry out audits if expertise is not already available. 369

6 13.2 Audit procedures When conducting an audit, it is necessary to plan each step so that the audit process is carried out effectively and the findings of the audit are used to implement any changes needed to improve moving and handling systems. Table 13.2 summarises the main steps in an audit. These are described in more detail in the following text. Table 13.2 Steps in conducting an audit Audit step Identify purposes and operational areas for audit Select or develop an audit tool Collect audit data Analyse data and collate findings Review operational procedures and implement changes Description Identify the purposes or benchmark standards, the type of audit to be carried out, the units or areas within the facility and specific topic areas of focus for the audit (e.g. risk assessment, equipment) Use an existing audit tool, such as a checklist, or develop one from existing tools Decide which units or wards are to be covered by the audit, arrange for audit data to be collected Collect all data and collate responses into a summary audit report. Ensure audit report is available to all staff Discuss audit report with managers and staff, and any changes needed as a result of the audit. Develop a plan for addressing any shortfalls identified 370 Step 1: Identify the purpose, operational areas and topic for the audit. This could be training, risk assessment, techniques or equipment and facility features. The selection might be based on information about recent moving and handling incidents, the length of time since a previous audit was carried out or significant changes made in management, staff or operational practices or policies in a unit. Decisions should also be made about the overall purpose of the audit, and what should happen as a result of the audit. An audit plan could be written as a series of statements or tasks on which the audit will focus and the intended outcomes from the audit. Prior to starting information collection, the audit organisers should ensure they have an understanding of the context for moving and handling activities in the unit or area being audited. The following questions may help to develop an understanding of the context: What are the types of service provided in the unit or facility being audited? What types of client are provided with services? Are there any special client care activities undertaken? What types of equipment and furniture are used in the unit or work area? How does this unit interact with other wards or units in the health facility? Step 2: Select or develop an audit tool. Examples of audit tools for specific topics are described later in this section. Once a tool has been developed or used several times,

7 Section 13: audits it is best to make only small changes at any one time so that the audit data collected can be compared with previous audits using the same tool. An exception might be if there is a need for a major revision of all the audit tools so that significant changes are made at the same time. Step 3: Collect data relevant to the audit. Check that the data to be collected are relevant to the purposes of the audit. To ensure thoroughness and make clear the limits of the audit, specify: The work units to be included, with any exceptions noted The healthcare staff to be involved in collecting the audit data The procedures or methods by which the audit data will be collected (see Boxes 13.3 and 13.4) Box 13.3 The time period in which audit data will be collected. Collecting audit data: A national audit in Australia The report from a national audit of manual handling in the health and community services industry in Australia noted the following methods for collecting audit information from 643 workplaces: A walkthrough inspection of the workplace Observation of high risk manual handling tasks Review of relevant management systems documentation Interviews with managers, supervisors, health and safety personnel and workers Completion of a safety culture and manual handling activity questionnaire by randomly selected workers. Source: Design 4 Health, 2005, p. 7 Step 4: Analyse the data and report the audit findings. When audit findings are collated they are sometimes compared with an expected standard (e.g. 90% or 100% compliance). It may also be relevant to identify reasons for specific findings (e.g. from comments in the completed audit forms). Comments collected during the audit may suggest a focus for improvement measures. Communicate the audit findings to managers and staff (make the findings readily available to staff), so that they know the outcomes from the audit process. 371

8 Box 13.4 Audit data collection methods during site visits In a multi site audit of 32 aged care facilities in New South Wales, Australia, the following methods were used to gather data at each facility visited. The audit was conducted over one day and involved: An on site meeting with management and key people, including the OHS coordinator/ chair OHS Committee/HSR [health and safety representative] Examining and evaluating documentation, such as OHS policies and procedures, risk assessments, reports and records of action to implement controls, training records and injury/incident records Conducting focus groups/interviews with employees and supervisors to determine issues, effectiveness of controls Interviewing employees who had sustained manual handling or occupational overuse syndrome (OOS) injuries within previous two years Reviewing operating procedures, training and supervisory practices and other risk control methods Conducting an exit meeting with the manager. Source: Aged Care Association Australia NSW, 2008, p. 9 Step 5: Review operating procedures and implement changes if needed. Once the results of the audit have been reported and discussed, make decisions about what changes, if any, are needed. Using an action plan to guide the implementation of recommendations is good practice. Following an audit, an action plan might include recommendations for staff to receive additional moving and handling training, and to address equipment shortages or lack of equipment access for staff. The action plan should include who has agreed to do what and by specified dates. Each recommendation needs to be clearly stated, with an individual designated as being responsible for it, and an agreed date for its completion. The next parts of this section provide information for audits on specific components of moving and handling programmes, including risk assessments, techniques, training, equipment and facility design and bariatric clients. Although the examples of audit items and tools outlined are specific to each area, in practice they are usually combined into a larger, more comprehensive audit tool (see example in Appendix 13.1). 372

9 Section 13: audits 13.3 Risk assessment audits As moving and handling activities involve risks, routine risk assessment procedures should be used when planning client moving and handling tasks so that risks can be controlled or reduced. Risk identification varies by setting and may be different in hospital wards, acute care, aged care, nursing homes and home care. When conducting a risk assessment audit, the following information sources can be considered: What information is kept about the profile of clients? (e.g. workplace profile) What forms or checklists are used for risk assessment? (e.g. client profiles) What central records are kept relating to client profiles? Is the client mobility assessment card visible near the client s bed? What movement risk assessments are conducted before moving clients? Depending on the type of facility and the types of risk assessment information that are available, an audit form can be developed based on a set of items that are suitable for the types of client and other aspects of the workplace profile for a facility. Table 13.3 shows an example of an audit form with items that might be used for a risk assessment audit. 373

10 Table 13.3 Examples of items for a risk assessment audit Number of clinical charts reviewed 1. Every bed has a client mobility assessment card visible (e.g. HASI= Hoist, Assist, Supervise, Independent) 2. The client mobility assessment card is completed and up to date 3. All clients have client profile forms in clinical notes 4. All client profiles have moving and handling plans for clients who are not independent 5. All client profile forms are up to date Analysis summary Formula for compliance % A) Number of criteria achieved (YES) B) Total number of criteria (excl those not applicable) Compliance A / B x 100 = % Yes No Partially Comments Recommendations/action Plan What Who When Complete Ward/unit Auditor Date Sign off by manager of ward/unit re agreed actions Manager Date Note: Form layout and some items adapted from Waitemata District Health Board. Key features of Table 13.3 include: How many clinical charts (or client profiles) have been reviewed in the unit or area Selection of a set of items that are relevant to the facility A specific response for each item and a comments box 374

11 Section 13: audits A summary calculation of the level of compliance (expressed as the percentage of yes responses to overall responses) for the unit or workplace area Recommendations and an action plan for improvements if needed. If an audit is to be conducted of the client profile for every occupied bed in a facility, a different form that lists individual clients is needed. Table 13.4 shows an example of the layout for an audit data sheet for use when recording information for each client. The items shown in the top row of the data sheet can be adapted to suit the particular needs of a facility or workplace or the type of audit. Table 13.4 Example of a risk assessment data sheet for an audit Client name or ID Mobility card visible? Mobility card completed Mobility card dated Client profile in notes Moving and handling plan present if needed Comments

12 13.4 Technique audits Gathering information for technique audits is generally more complex and time consuming than for other components of moving and handling programmes. Relevant information can be gathered in several ways: By the observation of ongoing moving and handling tasks in a work unit (see Box 13.5) Through asking staff to carry out specific transfer tasks with clients or other people Through surveys where staff report on how they carry out moving and handling tasks. Generally, the most effective information gathering method is observation of actual transfer tasks as they occur in a facility. However, this will typically involve considerable observation time. Where non compliance has been reported for specific moving and handling techniques (such as the use of hoists, slide sheets and other equipment), an auditor may wish to use informal interviews with staff to find out reasons for the non compliance. Information from informal interviews can be used directly to plan specific training for the staff, and to find out if any changes are needed to remove barriers to compliance. Auditors should check if the necessary equipment is readily accessible and available to staff. Audits of techniques should be carried out by staff or managers with relevant training and experience in moving and handling people. Box 13.5 Observation of manual handling tasks A national audit in Australia gave the following instructions for observing tasks as part of its data collection. 1. As a minimum, assess and record one high risk work task in each of 2 work areas. One of the work areas chosen MUST be a CLINICAL AREA. You may choose the work areas listed or choose another area based upon the workplace injury statistics, incident reports, discussions with the workplace, or identification during walk through inspection. 2. Assess the risk using your usual jurisdictional manual handling risk assessment process with the underlying principle that manual handling is deemed to be hazardous if the task contains repetitive or sustained movement, awkward posture or forces; high force; unstable or unbalanced loads; long duration; or exposure to environmental factors such as vibration. 3. Take appropriate compliance action as required as stipulated under the relevant jurisdictional legislation e.g. issuing of notices, directions, etc. Design 4 Health, 2005, p

13 Section 13: audits 13.5 Training audits Audits of training cover the extent to which staff involved in moving and handling people have adequate training. Training audits should be one of the easier types of audits to conduct, providing suitable records of training have been kept. Training records include: Lists of staff who have attended training, held by trainers Lists of staff from specific wards or units who have attended training, held by managers Lists of staff who did not attend their scheduled training sessions Training programme documents, such as the training schedule and topics covered in training Assessments of trainee competencies made by trainers Participant evaluations of training workshops held by trainers. Two specific areas of training that should be monitored and audited by unit or ward managers are induction training for newly employed staff, and annual updates or refresher training for existing staff. Unit managers need to monitor the training schedules for staff in their groups and arrange for staff to be released for training. Records should also be kept of staff scheduled for training but did not attend. Where an accident or near miss has been reported, the incident details should be assessed to determine whether additional training is required for the staff involved. To assist staff involved in moving and handling people, unit managers should maintain written records of induction training sessions and attendance lists, and annual follow up training, and any other relevant information related to moving and handling. These records should be checked during training audits. The person in charge of arranging or coordinating moving and handling training for the organisation should also keep records of staff attendance at training workshops. These should note the date and type of training completed by each staff member, and staff not attending training sessions they were scheduled to attend. 377

14 13.6 Equipment audits A wide range of moving and handling equipment is used in health and disability facilities. Common types of equipment included in moving and handling audits are slide sheets, PAT slides, mobile hoists, ceiling hoists, hoist slings and wheelchairs. Facility features for audits refer to building design features and fixtures that facilitate moving and handling, such as space to carry out client moving and handling tasks, ceiling tracking, equipment storage and hand bars in bathrooms. Generally, the managers of units responsible for storing and using equipment will be responsible for auditing equipment. Shared or pool equipment may need specific arrangements for auditing. Equipment audits should cover the availability of equipment within the unit or ward that is suitable for the client profile of the unit. Important features for an equipment audit include: Availability: Are there sufficient items of each type of equipment available where needed? Equipment storage: Can the equipment be stored in a suitable place when not in use? Ease of access: Are equipment items stored in places that make it easy for staff to access them? Proper labelling: Are fitness certificates and safe working loads (SWLs) clearly labelled on hoists and other equipment? Maintenance and servicing: Do visual checks of equipment identify any problems or potential problems (e.g. wobbly wheels on wheelchairs, tears in slings, infection control issues)? Battery charging: Are there suitable charging facilities for battery operated equipment? Examples of items that could be included in an equipment audit checklist are shown in Table Equipment items used in the community for clients cared for in their homes also need to be audited. The responsibility for ensuring that audits take place may need clarification within home care services, in conjunction with key institutions such as DHBs and the Accident Compensation Corporation (ACC). 378

15 Section 12: monitoring and evaluation Table 13.5 Examples of items for an equipment audit form Number of beds reviewed 1. The area shows evidence of slide sheets hanging beside beds occupied by clients whose mobility is impaired 2. There are two slide sheets hanging near each transfer board 3. The laundry system for slide sheets is operating as intended 4. The hoists seen have performance verification stickers that are within date 5. Adequate numbers and sizes of slings are available for hoists and are within date Number of hoists reviewed Yes No Partially Comments Note: Some items have been adapted from the Waitemata District Health Board audit form. 379

16 13.7 Facility audits Facility audits cover building design, workspaces and furniture related to moving and handling and should take place at least once a year. A facility audit should also take place after an incident or near miss, and before a facility or area is to be upgraded or renovated. Auditors should pick specific areas to do walkthrough observations with a list of items to check. Design features that impede or increase the risks of moving and handling tasks need to be noted. These include a lack of wheelchair access to particular areas, narrow corridors and doorways, ceiling tracks not covering bathrooms, insufficient space for two carers to assist a person in the toilet, inappropriate flooring that impedes the movement of equipment, and slippery flooring. Examples of items for a facility audit checklist are shown in Table Facility audits will generally come under health and safety sections in large organisations, and nurse managers or owners of small facilities. In some instances external auditors may be required to obtain accreditation for particular programmes offered, such as those from ACC. Walkthrough audits can be effective as a straightforward way of checking on equipment availability, storage, facility layout and some risk assessment details. An example is shown in Box A walkthrough audit can quickly pinpoint problems related to storage space, lack of access to equipment and poor facility design. 380

17 Section 13: audits Table 13.6 Examples of items for a facility design and workspace audit form 1. Is there enough space (minimum of 650mm clear space) on both sides of all beds for on bed movement of clients? 2. Is there enough space on at least one side of each bed to allow transfers on or off the bed (i.e. 1,200mm for wheelchairs/commodes; 1,500mm for mobile hoists; 1,500mm for slide sheet transfers from bed to trolley)? 3. Is there enough clear space at the foot of each bed to allow the safe movement and handling of clients (1,200mm in single rooms; 1500mm in two bed rooms)? 4. Can beds and client moving and handling equipment be easily moved around within bedrooms when required? 5. Can beds and client moving and handling equipment be easily moved in and out of bedrooms when required? (The recommended door opening is 1,200mm in aged care and 1350mm in acute care) 6. Are the storage cupboards functional in terms of location, doors and layout? 7. Are there enough storage cupboards to accommodate equipment? Note: Items adapted from WorkSafe Victoria, 2007, pp. 77, 81. Yes No Partially Comments 381

18 Box 13.6 Walkthrough audit of a hospital ward In March 2011, one of the review panel members walked through a relatively new ward in a large public hospital. The building had been opened around The purpose of the visit was to see how well moving and handling systems were incorporated into building design, equipment availability, risk assessment and communication related to safe moving and handling. What was found may well be common in recently built wards in New Zealand hospitals. Good points Ceiling tracking over beds in most client rooms One ceiling hoist and two mobile hoists available in storage rooms Small storage rooms provided for equipment. Bad points No client profiles or mobility information displayed in client rooms Ceiling tracking ends outside bathrooms (see photo 1) No hoists fitted in the ceiling tracking No SWL shown on ceiling tracking No slings available for use with hoists No slide sheets visible anywhere in the ward Toilet located in corner of bathroom, thus not providing carer access on both sides of toilet (see photo 2). Inadequate storage space for equipment Poor layout of storage space (mobile hoist stored in front of shelves, preventing access to shelves see photo 3). 382

19 Section 13: audits 13.8 Bariatric audits Auditors of facilities that have bariatric clients may wish to gather specific information regarding the extent to which planning for moving and handling bariatric clients is catered for. As noted in Section 14 Bariatric clients, the most desirable planning is to ensure that a bariatric pathway is available. A bariatric client pathway refers to the route that a client will take from first contact with the service provider through to the completion of their treatment. If there is no bariatric pathway available, a bariatric audit would then look at what specific provision, if any, has been made for bariatric clients. The following types of information will be relevant to a bariatric audit: Information on client admissions in the previous five years, documenting the number of bariatric clients being admitted each year and the wards or units where they have been receiving clinical or other care A list of bariatric equipment available An audit of moving and handling equipment to confirm which equipment items are suitable for use with bariatric clients Location of and staff access to bariatric equipment Specific wards or units within a facility designed for bariatric client care Information provided to staff about the moving and handling of bariatric clients Extent to which staff who move and handle bariatric clients have been given appropriate training A reporting system for incidents and accidents where bariatric clients were involved. 383

20 References and resources Aged Care Association Australia NSW. (2008). Manual Handling Audits of Aged Care Facilities. Aged Care Association Australia NSW/Aged & Community Services Association of NSW & ACT. Retrieved 17 May 2011 from Department of Health (UK). (2005). A Safer Place for Patients: Learning to improve patient safety. Department of Health and National Audit Office. Retrieved 17 May 2011 from Design 4 Health. (2005). Design 4 Health National Manual Handling Campaign 2004: Industry summary report. Retrieved 20 August 2009 from Dorset Primary Care Trust. (2009). Manual Handling (Safer Moving and Handling) Policy. Retrieved 17 May 2011 from Surrey NHS. (2009). Patient Handling Policy. Retrieved 17 May 2011 from WorkSafe Victoria. (2007). A Guide to Designing Workplaces for Safer Handling of People: For health, aged care, rehabilitation and disability facilities. Melbourne: Victorian WorkCover Authority. 384

21 Section 13: audits Appendix 13.1 Moving and handling audit form (Adapted from Waitemata District Health Board audit form) Number of clinical charts reviewed If Partial for any criteria, state the number of correct items in Comments. Analysis summary 1. Every bed has a mobility card visible 2. The mobility card is completed and up to date 3. Each client has a client profile form in clinical notes 4. All client profile forms are up to date 5. The area displays publicly a client/ visitor information poster 6. Slide sheets are adequately maintained 7. The area shows evidence of slide sheets hanging beside clients beds once allocated 8. Are there two slide sheets hanging near each transfer board? 9. Each hoist performance verification sticker is present and within date 10. Adequate numbers and sizes of hoist accessories are available and within date Analysis summary Formula for compliance % A) Number of criteria achieved (YES) B) Total number of criteria (excl those not applicable) Compliance A / B x 100 = % Yes No Partially Comments Recommendations/action Plan What Who When Complete Ward/unit Auditor Date Sign off by manager of ward/unit re agreed actions Manager Date 385

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